LARC is the most reliable method of contraception for an extensive period of time without you having to remember to take or use them in order for them to work. It includes injections, intrauterine contraception (IUCs) and subdermal contraceptive implants (e.g. Nexplanon).

Yes No

Do you want Long-acting reversible contraceptives (LARC)? Yes No

If you only want an STI check-up, you can either order a home self-test kit or make an appointment.If you are a woman and want to start, continue or change a method of contraception, please make an appointment to come in to see us.What would you like to do?

If you are a woman and regard yourself to be someone at high risk of infection you may prefer to attend clinic to discuss additional testing (+/- vaccination if in high risk group)

Order a home self-test kit Make an appointment at a clinic

Are you over 18? Yes No

Home self-test kits are available for Chlamydia, Gonorrhoea, HIV and Syphilis.

We will post your kit to you. You take your own samples and send it back. You’ll get your results by text or we will call you.

We can only offer home self-test kits to people who live within the Surrey County Council area.

Please enter your post code so we can check if you are eligible for this service.

Our home self-test kits for men include a urine test for Chlamydia and Gonorrhoea.

Some men may need additional tests.

If you have had anal sex or oral sex with a man, we will also include swabs (like a cotton-bud).

We automatically include a finger prick test for HIV and Syphilis if we think you need one based on your answers. You can also choose to add this.

The next two questions will help us to work what you need.Your answers will be confidential.

If this is your first sexual health check, please answer these questions about all of your sexual experiences.

If you have had a sexual health check before, please answer these questions based on what has happened since the last time you had a sexual health check.

Our home self-test kits for women include a vaginal swab for Chlamydia and Gonorrhoea.

Some women may need additional tests.

If you have had anal sex or oral sex with a man, we will also include swabs (like a cotton-bud).

The next two questions will help us to work out if you need swabs and which ones you need.Your answers will be confidential.

If this is your first sexual health check, please answer these questions about all of your sexual experiences.

If you have had a sexual health check before, please answer these questions based on what has happened since the last time you had a sexual health check.

Have you had a penis (or a shared sex toy) inserted in to your bum?

We are asking this so that we know whether you need a swab for your rectum.

Yes No

Have you sucked a penis?

We are asking this so that we know whether you need a swab for your throat.

Yes No

We can test your blood for HIV and Syphilis using a finger prick test.

If you have not had an HIV test before, we recommend you have one. We also recommend regular testing for people who are at higher risk.

If you are not sure whether you need an HIV or Syphilis test or you want more information about HIV testing, visit this page.

You can do this now because you will be able to come back to this form once you’ve read the information.

Do you want a finger prick test for HIV and Syphilis? Yes No

We will be sending you a home self-test kit that includes...

We will post your kit to you. You take your own samples and send it back.
You’ll get your results by text or we will call you.

You can only order a home self-test kit for yourself. Please do not try to place orders for other people.

Please complete the form below.

We will record these details in your patient record and share them with our third party supplier, TDL (The Doctors Laboratory), who will supply your home self-test kit and carry out the testing on your returned samples.

I agree that CNWL can share my details with TDL *

Date of Birth

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Note: Your eligibility to receive a self-test kit depends on your postcode and changing this may reset the above information. Only UK mobile numbers will be accepted.

We will record whether you are male or female based on the kit you have ordered.

The information below is required for anonymous bulk reporting for health planning. The information in reports cannot be linked to you as an individual and will only be shared for NHS purposes.

When you press submit, we will send you a validation code by text to confirm your mobile number.